Diagnosis and Nonoperative Management of Uncomplicated Jejunal Diverticulitis: A Case-Based Review

Abstract

Diverticulosis is characterized by sac-like bulges of the mucosa through weakened portions of the intestinal wall, and is a common pathology observed in adult patient populations. The majority of diverticular disease and associated complications, such as inflammation of diverticula, form within the colon, with less frequent cases of diverticular disease observed in the small bowel. We present the case of a 48-year-old female who presented to the emergency department with a two-day history of abdominal pain, fever, and nausea. Upon admission, vital signs indicated fever and laboratory analysis demonstrated elevated white blood cell count. The patient’s workup included a computed tomography (CT) scan of the abdomen which revealed diffuse small bowel diverticulitis with surrounding inflammation, lymph node enlargement, and bowel wall thickening. CT scan of the abdomen with evidence of diverticula in the bowel wall is diagnostic of diverticulosis. Treatment could include bowel rest, clear liquid diet, broad-spectrum antibiotics, or surgical intervention. This case emphasizes the importance of CT imaging and consideration of broad differential diagnosis in patients presenting with abdominal pain due to the rare presentation of small bowel diverticulitis and aims to contribute to the current understanding and treatment of clinically significant diverticular pathologies.

1. Introduction

Diverticulosis is a condition that involves the projection of mucosa or submucosa through structurally weak portions of the intestinal wall resulting in a sac-like bulge [1]. Diverticular disease is a common occurrence with 95% of the diverticula forming within the sigmoid colon [1]. Although diverticulosis often remains asymptomatic, it can be a significant cause of gastrointestinal (GI) distress and may progress to more serious complications. When symptoms do manifest, the condition is generally identified as a part of diverticular disease, which can include a spectrum of disorders defined as uncomplicated diverticulitis or complicated diverticulitis. Uncomplicated diverticulitis is disease limited to the diverticula with colonic wall thickening and pericolonic inflammation, whereas complicated diverticulitis includes complications such as GI bleeding, strictures, fistulas, abscess formation, peritonitis, obstruction, and perforation [2]. The majority of patients with diverticulitis present with uncomplicated diverticulitis, with an estimated prevalence of 88%, compared to 12% of individuals with complicated diverticulitis [2].

Diverticulitis involves inflammation of diverticula and occurs in 4–15% of patients with diverticulosis [1,3]. An even smaller percentage of these patients have diverticulitis that is isolated to the small bowel, most cases of which are caused by a genetic abnormality known as Meckel’s diverticulum. Non-Meckel’s small bowel diverticulitis is rare and is typically asymptomatic. However, when symptomatic, small bowel diverticulitis can present with symptoms such as abdominal discomfort, bloating, nausea, vomiting, diarrhea, early satiety, and other nonspecific GI complaints.

The exact underlying pathophysiology of diverticulosis has not been entirely elucidated; however, several risk factors, to include both genetic and environmental factors, have been associated with the development of diverticula [4]. Risk factors that have been associated with the development of diverticular disease include chronic constipation, a low-fiber diet, lifestyle habits such as tobacco use, alcohol and red meat intake, and comorbid conditions such as diabetes and hypertension. Emerging research also suggests that intestinal microenvironment alterations and overall gut health may also play a role in the development of diverticular disease [5,6,7].

Diagnosis typically occurs as an incidental finding in patients receiving a GI workup, which may include an endoscopy or contrast imaging studies. In the case of symptomatic small bowel diverticulitis, treatment will depend on the patient’s presentation and presence of complications, but may involve conservative measures such as bowel rest, dietary changes to include low-fiber and liquid diet considerations and may include treatment with broad-spectrum antibiotics to manage inflammation and infection. However, in cases of severe complications, such as bleeding, obstruction, abscess or fistula formation, or bowel perforation, surgical intervention may be warranted [3].

This case-based review aims to contribute to the current body of medical literature with emphasis on the clinical relevance of rare diverticular complications and to provide an overview of recommended diagnostic and treatment strategies.

2. Case Presentation

We present the case of a 48-year-old female with no significant past medical history who presented to the emergency department with a two-day history of diffuse abdominal pain. Her abdominal pain was accompanied by fever and nausea, she denied any additional symptoms to include vomiting, diarrhea, constipation, hematochezia, melena, hematuria, hemoptysis, jaundice, early satiety, steatorrhea, or bloating. The patient denied having experienced any similar episodes of abdominal pain in the past, and her past surgical history and family history were noncontributory. Vital signs indicated fever, physical exam revealed mid-abdominal pain on palpation, and laboratory analysis demonstrated an elevated white blood cell count of 13,700 cells per microliter (cells/µL) (reference range 4000–11,000 cells/µL).

Imaging evaluation included contrast-enhanced CT of the abdomen, which illustrated diffuse small bowel diverticulitis with surrounding inflammation and lymph node enlargement as seen in Figure 1A,B and Figure 2. As displayed in Figure 2, bowel wall thickening was also noted on imaging.

The patient was admitted for further evaluation and inpatient treatment with intravenous (IV) normal saline and IV amoxicillin-clavulanate. Within one day of starting IV fluids and antibiotics, the patient’s fever resolved. The patient’s abdominal pain, nausea, and elevated white blood cell count resolved three days after admission and the patient was cleared for discharge. Upon discharge, she was instructed to take oral amoxicillin-clavulanate for seven days and follow up with her primary care physician and outpatient GI physician.

3. Discussion

Diverticular disease involves the sigmoid colon in 95% of patients [1]. Small bowel diverticular disease is less common, predominantly arising in the duodenum in 79% of cases and the jejunum or ileum in 18% of cases [8]. The prevalence of duodenal diverticula ranges from 2–20% based on the imaging study conducted, to include barium swallow, endoscopic retrograde cholangiopancreatography, or autopsy, and incidence of diverticular disease has been shown to increase with age [8]. Jejunal diverticular disease has a prevalence of 0.5–7% based on some studies [8]. Like colonic diverticula, patients with small bowel diverticula are typically asymptomatic [1,8]. Duodenal diverticula can occasionally present with postprandial epigastric pain or vomiting due to obstruction. The two most common presenting signs of jejunoileal diverticula are abdominal pain and diarrhea [9]. Small bowel diverticulitis, inflammation of the diverticula in the bowel, can present with epigastric pain, bloating, fever, early satiety, diarrhea, and steatorrhea [8]. The median age of presentation of small bowel diverticulitis is 73.1 years, with the most common complications of perforation in 6% of patients and abscess in 6% of patients [10]. Jejunoileal diverticula are usually localized to the proximal jejunum and are typically composed of mucosa and submucosa or all jejunal wall layers. It is believed that the formation of these diverticula is linked to the onset of intestinal dysmotility and high intraluminal pressures that can affect the jejunal wall [1,8].

In this case, the patient did not have the classic presentation of left lower quadrant pain but presented with mid-abdominal pain, fever, nausea, and leukocytosis. The patient did not have any pertinent past medical or surgical history to suggest a diagnosis of small bowel diverticulitis, and did not fall within the expected age range for clinical presentation [1,10]. CT imaging of the abdomen showed inflammation of the jejunum, lymph node enlargement, and bowel wall thickening indicative of small bowel diverticulitis.

The Hinchey classification is a commonly used tool for grading the severity of patients presenting with colonic diverticulitis [8]. The modified Hinchey classification, as seen in

Table 1. Modified Hinchey classification system for grading severity of diverticulitis [11,12].

Modified Hinchey Classification	Grading Criteria
IA	Presence of inflammatory changes with pericolonic fat stranding and without fluid collection.
IB	Presence of inflammatory changes with the addition of abscess formation less than 4 cm.
II	Presence of abscess formation greater than 4 cm, pelvic abscesses, or interloop abscesses.
III	Presence of purulent peritonitis.
IV	Presence of feculent peritonitis.

, describes the progressive pathological changes in colonic diverticulitis with increasing severity of disease to guide management. It is of note that there is no current formal classification system for grading the severity of small bowel diverticulitis due to the rare nature of symptomatic small bowel disease. Therefore, the application of the Hinchey or modified Hinchey systems to cases of small bowel diverticulitis is limited.

Diagnosis of small bowel diverticulosis is typically an incidental finding upon upper endoscopy or due to evaluation of abdominal pain prompting further imaging [10]. Diagnosis can be established through imaging modalities such as upper GI series with small bowel follow-through, CT, magnetic resonance imaging (MRI), and endoscopy; however, complications of small bowel diverticulitis can only be visualized with CT or MRI imaging [13]. Although the patient did not fit the classic clinical presentation of diverticulitis, imaging was an important measure to rule out GI disorders and prevent further complications such as small bowel obstruction, GI bleeding, or obstructive jaundice [13].

Symptomatic jejunal diverticulitis is difficult to diagnose due to its rarity and nonspecific clinical presentation. This patient’s presentation of abdominal pain, nausea, and fever overlap with a wide range of more prevalent gastrointestinal disorders, including colonic diverticulitis, appendicitis, cholecystitis, gastroenteritis, pancreatitis, small bowel obstruction (SBO), and small intestine bacterial overgrowth (SIBO) [1,4,8]. Compounding the diagnostic challenge, jejunal diverticulitis may be further complicated by pancreatitis, SBO, SIBO, or gastrointestinal bleeding [8]. Although absent in this patient, additional symptoms such as vomiting, diarrhea, early satiety, and bloating can also be seen in cases of jejunal diverticulitis, further complicating the clinical picture given their overlap with many of the prior differential diagnoses. These complexities are important to recognize for diagnostically challenging cases as misdiagnosis, unnecessary laboratory testing, or unnecessary imaging may impact the time to intervention. This is an important consideration, as previous studies on managing patients with diverticulitis have demonstrated that delays in care are strongly associated with increased mortality, increased incidence of complications, and an increase in postoperative length of stay [14,15]. As a result, the timely identification of jejunal diverticulitis relies on the thorough exclusion of more prevalent conditions, with the aid of appropriate diagnostic imaging. CT scans demonstrate an instrumental role by rapidly identifying features that are specific to the disease process, enabling a prompt and accurate diagnosis [10,13].

While there is no universal consensus on management of small bowel diverticulitis, treatment approaches are similar to colonic diverticulitis, ranging from conservative management to surgical interventions based on the Hinchey classification and complications [16]. Previous reported cases of uncomplicated jejunal diverticulitis have demonstrated treatment efficacy with antibiotics and bowel rest alone [17,18]. Novak et al. also reported a case of jejunal diverticulitis with abscess formation that was managed nonoperatively with antibiotics and CT-guided abscess drainage that yielded a positive clinical outcome [18]. The current mainstay of treatment for complicated jejunal diverticulitis involves surgical resection of the affected portion of the small bowel [19].

Compared to the treatment of jejunal diverticulitis, the majority of patients with acute uncomplicated colonic diverticulitis may be treated nonoperatively with the mainstay of therapy including antibiotics, fluid replenishment, and pain management [20]. In this case, treatment with IV amoxicillin-clavulanate, a penicillin derivative combined with a beta-lactamase inhibitor, was chosen due to extended-spectrum coverage of gram-positive and gram-negative bacteria. Additionally, observation alone may be reasonable in select patients, as demonstrated by a recent meta-analysis on patients with Hinchey stage 1A uncomplicated disease [21]. Due to high mortality rates associated with surgical management of Hinchey stage II disease, surgical intervention is reserved for Hinchey stage III and stage IV disease [22]. While management of jejunal diverticulitis currently shares a similar approach to the management of colonic diverticulitis, more research is necessary to develop appropriate treatment recommendations for the improvement of patient outcomes.

Following resolution of acute diverticulitis, outpatient management is important to monitor for recurrence and ensure full recovery. Follow up is guided by the severity of the patient’s condition and treatment approach. Patients managed with conservative diet management and antibiotic treatment should be encouraged to adopt healthy lifestyle changes including weight management, tobacco cessation, a fiber-rich diet and regular physical activity to reduce the risk of recurrence. In patients undergoing treatment with surgical intervention, outpatient follow up typically consists of routine postoperative evaluation to assess wound healing, monitoring for infection, and evaluating bowel function. Repeat imaging may be necessary and long-term management can also involve encouragement of healthy lifestyle interventions. Evidence based guidelines from the American Gastrointestinal Association also offer other suggestions such as advising patients with prior history of diverticulitis to avoid using non-aspirin nonsteroidal anti-inflammatory drugs if possible, avoiding the use of mesalamine or probiotics after acute uncomplicated diverticulitis, and advising patients with diverticular disease to consider vigorous physical activity [23].

4. Conclusions

This case report highlights a rare instance of small bowel diverticulosis and an associated complication of jejunal diverticulitis, emphasizing the importance of identifying all possible GI pathologies, especially in a patient that does not fit the classic demographic or clinical presentation for pathologies such as diverticulitis. CT imaging indicated small bowel diverticulitis, which could have been overlooked due to the patient’s presentation of nonspecific symptoms of abdominal pain, nausea, and fever. Using CT as a first-line diagnostic tool compared to other imaging modalities in suspected cases of small bowel diverticulitis is necessary to ensure timely diagnosis and treatment, prevent complications, and improve patient outcomes. In this case, timely diagnosis and efficient conservative management enabled the patient to avoid surgical intervention, possible complications, or prolonged hospitalization. This case report aims to contribute to the current understanding of the diagnosis and management of small bowel diverticulitis and associated complications.